By Michael Fox
For many psychotherapists and counsellors working outside drug treatment settings, addiction forms part of their “exclusion criteria” when assessing the person’s suitability for therapy. This is not surprising. Drug dependency is perceived as quite a specialised area. It is best left to the drug treatment centre or hospital. In such settings a range of treatment options can be offered. This may include a spell of residential treatment. This may be necessary in order to ‘hold’ the person (metaphorically & psycho-dynamically) while abstinence and early recovery is reached. There may be a negative feeling about working with drug dependent clients. This is reflective, perhaps, of the ‘disembodied self ‘ of the client, with whom meaningful contact may be difficult and whose pain may not be easily seen. Allied to this, the use of individual psychotherapy is not usual as a singular approach to addiction. (1)
However, as counsellors and therapists in drug treatment and rehabilitation centres grapple with the complexity of addiction, many issues come to the surface for the client. Issues that can “make or break” the recovery process.
The purpose of this article is to give the reader an insight into how these issues may underlie the addictive process, how they might emerge during group therapy and how the group itself is used as a therapeutic medium.
Yalom (2), found that Group therapy generally has a number of therapeutic factors. He defined these as: installation of hope, universality, imparting of information, altruism, development of socialising techniques, imitative behaviour, catharsis, corrective re-enactment of the primary family group, existential factors, group cohesiveness and interpersonal learning.
The special benefits of group therapy in addiction include:
1. Offering hope – this can come from seeing a person who is “further” in recovery, doing well. 2. Positive peer pressure. 3. Testing reality. Distorted by drug use, what are the basic needs of people? Do these include chemicals? Are “straight”, (non-drug using), people boring? 4. Offering immediate feedback on behaviour. 5. In the process of therapy, the nature of drug use is confronted. This is always done with respect, concern and courtesy.
6. The needs for closeness and friendship are met. These are vital to recovery.
7. Groups help to lessen the stigma of addiction, of having lost control of one’s life.
8. The group allows the recovering persons to enact their “actor” and their “observer” parts simultaneously. This enhances self-awareness. 9. Avoidance, denial, insincerity, poor motivation and low self-esteem can readily be seen in the group, both by therapists and other group members.
10. The need for accurate information is great among recovering drug users. Health concerns are often prominent. Group therapy can meet this need.
Relevant Psychotherapeutic Perspectives
It is known that addiction is powerfully maintained by the socio-cultural milieu. However, recent research has also focused on addiction as adaptation, and as an attempt to deal with psychological suffering. (3) While the striving for pleasure (“kicks”) is acknowledged (especially in the early stages of drug use), the deeper desire, and what addiction is largely about, is producing a reduction in distress by using chemicals.
The early environment of the child is acknowledged increasingly as playing a crucial role in the later development of addiction. Here the work of Winnicott (4) on the mother/child dyad, in which there is well attuned, “good enough” mothering, and where the child internalises the caring environment, is important for understanding the addictive core of the self. Psychoanalytic research, such as that of Kohut (5), places a great emphasis on the total experience of the self, its wholeness or fragmentation, and of the confirming, mirroring and rewarding inputs of the other. Vulnerabilities in self-care, self-development and self-esteem are now considered from such viewpoints.
To understand the development of addiction and the relapse into addiction, the central importance of regulation of feelings is recognised. (6, 7) Addicts themselves frequently describe their use of drugs as making them feel “normal” or ‘OK’, not overwhelmed, etc. Substances can now be seen as “structural prostheses”, to boost self-esteem, lift persistently low moods and calm anxiety. If making meaningful and closer social contact for adolescents is difficult, it may be seen how drugs can mask this “inner sense of lacking” they experience. Perhaps the most recent example of this is the way the drug “Ecstasy” (MDMA) is used.
It is important to remember that at a deep and personal level the individual’s investment in drugs may be massive. For the user it is a “good object”, a “miracle drug”, that lessens psychic pain and masks vulnerability. The more and the longer the person takes drugs, the more the understanding of his/her need for drugs, is beyond the threshold of awareness. As long as drug use continues, the person who could use this information most is denying him/herself the opportunity of knowing it.
Tackling Addiction in Group Therapy
It is reassuring, when working with addiction in groups, that certain patterns can be anticipated and are repeated time and time again, in different kinds of groups for addiction. Groups can be designed for early or chronic drug dependency, residential or non-residential, can be gender specific, drug specific or can be focused on, for example, early abstinence issues, relapse prevention issues or ongoing recovery issues. What is also reassuring is that the entire context of the individual’s problem (interpersonal, intra personal) can potentially, be played out in the safety of a therapy group.
It is not surprising that the initial reaction of the addicted person to joining a group can be mistrust, anxiety, defensiveness, and resistance. The process of working on a problem (and one’s self) in the company of others is a new and profoundly challenging experience.
The addicted person may react in ways that misrepresent the self. Some have a customary defensive position. They may paint themselves in caricature, reacting with a presence of “not caring” or not being bothered about who likes them. Frequently, the “addicted persona” is used in the group to defend against challenge and change.
Some adopt strong, socially acceptable or unacceptable behaviours. These are often used to hide the shame that life is out of control. The addicted person may expect the therapist to hold the responsibility for his/her presence and work in the group. There tends to be an oversimplification of the nature of addiction and a defensive classification of the self. One person replied to an enquiry about why he used a drug by saying: “Why did I use? – Because I’m an addict. Why did the birdy eat the seed?”…
It often appears that the “natural” course of a group in drug treatment is to disband or disintegrate. This is reflective, perhaps, of the inner sense of fragmentation and alienation that exists among drug users. Added to this is the person’s learned expectation that things like this will fail. (“I have failed so often before.”) Individuals often do their best to avoid attending the group, arrive consistently late and give all manner of excuses.
The task of the therapist is to create from the outset, safe, consistent and reliable boundaries for the group. These will include; timekeeping, attendance, not using before the group, no verbal or other abuse in the group etc. These boundaries then have to be enforced and are often challenged by group members. Individuals may have been victims of violated boundaries and may have been abused early in life. Added to this, the life of the addicted person often involves few healthy boundaries. It is in maintaining this safe, consistent structure that clients settle down. This in itself may be a therapeutic factor.
The group process itself may not be inherently pleasurable at first. This is difficult for someone who for years has been trying to maintain an addicted state of avoidance of pain. The group soon progresses into a working phase by keeping a high value on support, structure and boundaries. The individual, who has despaired of ever feeling better, can see that homeostasis will come as long as he/she avoids relapse. The connection with others and feeling understood within the group is vital. (The addicted person is often highly judgmental of self.) For now, the prospect of relating to “straight” people may still seem remote. Ambivalence continues well into the group process. The part of the person wanting to remain “stoned” fights the part that wants to recover. As self-disclosure increases, the individual realises the struggle is not a solitary one. It is often only when the person internalises the caring, dependable qualities of the group, that the group itself becomes a “good object”. Inner self-regulation may begin to develop.
At the early stages, the achievement of abstinence goals is critical. This might mean goal setting, planning strategies and behavioural change. For the client this may be as simple as making a decision to turn right or left when leaving the clinic, so as to avoid the person selling drugs.
Gradually, individual responsibility is regained and the realisation that real choice can only occur when recovery is achieved. The task of the therapist is to continue to “tie-in” the chaos, crisis, dysfunction, depression, and suffering of the addicted person, with drug use. The extent to which the person is able or willing to make this connection is crucial. It is often resisted for some considerable time.
The therapist is simultaneously a manager of the group activities, an observer and a participant (as therapist), in the early stages. Most groups also have a co-therapist.
The approach has to be emphatic of the suffering of the addict at all times, respectful of his/her integrity but nevertheless, firm and consistent. For the individual, there is a gradual “reclaiming of the body” as the person learns to experience feelings, not mediated by substances, and begins to differentiate them. Many areas of unfinished business may emerge. Drug use may have delayed the working through of experiences such as shame, from childhood, the aftermath of emotional, physical or sexual abuse, the resolution of conflict about a parent who may have been alcoholic, or loss and grief. The person may also heed the group to come to terms with health consequences of intravenous drug taking – such as being HIV+ or having Hepatitis.
There are many facets of group therapy beyond the scope of this brief description. In summary, the group therapy situation provides a structure that allows for the meaningful and detailed exploration of issues in addiction and in recovery. This forms part of a programme that also includes individual counselling, family therapy, self help and education, providing a framework for drug dependency to be overcome.
1. Rounsaville, B & Carroll, K (1992) Individual Psychotherapy for Drug Abusers; in Lowenson, J, Ruiz, P. & Milman, R. (eds) Substance Abuse – A Comprehensive Textbook. Williams & Wilkins, Baltimore.
2. Yalom, I (1985) The Theory and Practice of Group Psychotherapy. Basic Books, New York.
3. Khantzian, E.J. (1982) Psychological (Structural) Vulnerabilities and the Specific Appeal of Narcotics. NY Academy of Science.
4. Winnicott, D.W. (1965) The Maturational Processes and the Facilitating Environment. International Universities Press.
5. Kohut, H (1971) The Analysis of the Self. NY International Universities Press.
6. Chein, I., Gerard, D.L., Lee, R.S., Rosenfield, E.(1964) The Road to “H”, New York, Basic Books
7. Marlatt, G.A. Situational Determinants of Relapse and Skill Training Interventions. (1985): In Marlatt, G.A., Gordon, J. (eds), Relapse Prevention – A Self Control Strategy for the Maintenance of Behaviour Change. New York, Guilford.
Michael Fox is an accredited member of IAHIP & IAC. He works part-time as a group therapist at the National Drug Treatment Centre, Trinity Court, 30/31 Pearse Street, Dublin 2. Tel: 6771122
The NDTC provides assessment, treatment and advisory services for the full range of drug misuse and dependency problems.